• Migraine headache (HA): A chronic, recurrent episodic, stereotypical HA syndrome not caused by intracranial or systemic disease (but neural-based)
– ± associated migraine features; ± aura
– International Headache Society (IHS): Diagnostic criteria and migraine subtypes: Migraine without aura →
A. At least 5 attacks fulfilling B–D
B. HA lasting for 4–72 hours
C. HA with at least 2 of the following: Unilateral location, pulsing quality, moderate to severe intensity, aggravation by or avoidance of routine activity
D. HA accompanied by at least 1 of following: Nausea and/or vomiting, photophobia, or phonophobia
E. Not attributed to another disorder
• Cluster HA: Episodic, short-lived attacks, clustered temporally, followed by pain-free interval.
– IHS criteria:
– A. 5 attacks fulfilling B–D
– B. Severe, unilateral, orbital, supraorbital, or temporal pain lasting 15–80 minutes
– C. At least 1 ipsilateral feature: Conjunctival injection/lacrimation, nasal congestion/rhinorrhea, eyelid edema, forehead/facial sweating, ptosis, miosis, restlessness or agitation
– D. Frequency: every other day to 8 attacks/day
– E. Not attributed to another disorder
– Characteristic circadian & circannual features
• Initial determinations: 1) Primary (no underlying intracranial or systemic disease) versus secondary HA 2) New onset versus chronic
– Requires emergent evaluation (e.g., neuroimaging ± lumbar puncture (LP)):
– Acute onset, maximal at onset or focal signs; Progressive symptoms and signs; systemic symptoms (e.g., fever)
– Other worrisome features: Onset fourth to fifth decade, accelerating pattern, history of malignancy or HIV, significant change in HA pattern, exacerbation with position change, exertion, sexual activity, or Valsalva
Migraine: ♀:♂ 3:1; cumulative lifetime: ♀ 43%, ♂ 18%. cluster: ♂:♀ 8:1
Migraine 12–15%; cluster ∼69/100,000
Family history: ↑ Risk by 50% versus controls
Familial hemiplegic migraine 1, 19p13
Identification and avoidance of migraine triggers
Central activation of pain sensitive cranial structures; serotonergic neurotransmission dysfunction; central pain sensitization
Hereditary; pattern and mode of inheritance unclear; multiple genes contribute
COMMONLY ASSOCIATED CONDITIONS
Depression, panic disorder, epilepsy, asthma, non-HA pain
• See IHS criteria
• Assess: Inciting event, new onset/de novo versus chronic/recurrent, quality, duration, location, and time course
– Characteristic frequency and symptom pattern?
– Exacerbating or alleviating factors? Triggers?
– Position, posture, or Valsalva related?
– Age >50 years: Temporal arteritis ROS?
– Time-intensity relationship:
– Subarachnoid hemorrhage (SAH): Maximal intensity at onset, that is, “thunder-clap”
– Cluster: Peaks over 3–5 minutes, maximal for 1–2 hours, tapers off.
– Migraine: Escalates over hour(s), lasts hours to days.
– Migraine features? Aura, nausea, vomiting, photophobia, and phonophobia
– Cluster: Excruciating, acute, unilateral periorbital pain; crescendo within 5 minutes; ipsilateral autonomic features
Pathognomonic: Provoked by ETOH in ∼70%
• Assess additional symptoms: Transient visual obscurations, vertigo, meningismus, amenorrhea, galactorrhea, fever, purulent nasal discharge, myalgias, scalp tenderness, jaw claudication, and cognitive dysfunction.
– History of focal neurological symptoms?
• Past medical, psychiatric, and medication history: Neoplasm, aneurysm, or HIV history?
Complete neurological exam including funduscopy: Normal except for transient aura signs.
DIAGNOSTIC TESTS & INTERPRETATION
Initial lab tests
Exclusion of secondary causes: Metabolic panel, CBC/Platelets, ESR and CRP for age >50 years
Follow-up & special considerations
ANA, Anti-DS DNA Ab, Arterial blood gas, sleep study to r/o sleep apnea, anti TSH-receptor Ab, → tailor to individual patient
• New onset HA of non-urgent nature: MRI
• Acute, severe HA, or focal signs: Urgent non-contrast CT
Follow-up & special considerations
• MRV for venous sinus thrombosis and work-up of idiopathic intracranial hypertension (IIH)
• CTA or MRI/A with axial T1 fat suppression: Optimal for ruling out dissection
• LP must be obtained for suspected SAH if CT negative (prior to MRI)
• Visual aura: Include visual field to exclude homonymous defects indicating parenchymal disease
• Clinical impact scales: MIDAS, HIT, MIBS, MSQ, MPQ-5